Welcome to CDC stacks | An evaluation of a national program to improve linkage-to-care early enrolment and retention in HIV care among clients HIV-diagnosed in two settings in Swaziland, 2011-2012 - 42910 | Stephen B. Thacker CDC Library collection

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Background: To help document and improve early enrollment and retention in HIV care in 2011, the Swaziland Ministry of Health implemented a new set of standard operating procedures on linkage and retention (National SOP). The National SOP was implemented as part of two programs: the Soka Uncobe male circumcision campaign (SOKA) in 2011 and 2012, during which HIV testing was facility-based, and the Swaziland HIV Incidence Measurement Survey (SHIMS) in 2011, during which HIV testing was home-based. The purpose of this study was to evaluate (1) compliance with the National SOP, and (2) early enrollment and retention in HIV care among newly HIV diagnosed SOKA and SHIMS clients.

Methods: The study included two components. Component I was a retrospective cohort analysis of 1,105 newly HIV-diagnosed SOKA and SHIMS clients. Routinely collected program data on this retrospective cohort were abstracted from multiple sources including HIV testing and counseling forms (referral forms), and records maintained at facilities where clients were referred and elected to enroll in HIV care. Component II was a telephone survey of clients who were not initially verified to have enrolled in care at facilities to which they were referred. The brief survey ascertained if and where the client enrolled in care, and for those clients who did not enroll, reasons for not enrolling in care. For clients who reported enrolling in care, study personnel visited facilities to verify enrollment and abstracted data from client records in accordance with Component I procedures.

Results: The 1,105 clients (494 SHIMS females, 294 SHIMS males, 317 SOKA males), diagnosed with HIV at a median (Q1-Q3) age of 29 (24-35) years, were referred to 69 HIV care facilities throughout Swaziland (18 in Hhohho, 16 Lubombo, 17 Manzini, 18 Shiselweni). Most clients were referred to government (71.4%) facilities categorized as clinics (47.4%) or hospitals (34.4%). At referral facilities, referral forms were located for only half (46.8%) of the clients; few (9.6%) were recorded in the appointment register and called either before (0.3%) or after (4.9%) their appointment. Of 267 clients interviewed, few (9.0%) reported receiving a phone call from the referral facility. After adjusting for non-response, of 1,105 clients, an estimated 464 (41.9%) enrolled in HIV care overall, and 155 (14.0%), 192 (17.3%), 269 (24.3%), 342 (30.9%), and 409 (37.0%) within 3, 6, 12, 18, and 24 months of diagnosis, respectively. Of interviewed clients, the most common reasons reported for not enrolling in care included perceived good health, and care that is inconvenient or costly. Of 300 clients verified to have enrolled in HIV care, at enrollment, 66.0% were ART eligible based on national guidelines (CD4 < 350 cells/μl or WHO stage III or IV). Of ART-eligible clients at enrollment, 94.4% were initiated on ART and 86.5% were retained on ART two years after initiation. Of the few clients who enrolled in pre-ART care, 54.8% and 35.1% were retained in pre-ART care one and two years after enrollment, respectively.

Conclusion: Of over one thousand clients newly HIV diagnosed in two settings in Swaziland in 2011 and 2012, very few received linkage services in accordance with the National SOP, and less than 40% were estimated to have enrolled in HIV care within two year of their diagnosis. Of the few clients found to enroll in pre-ART care, most were not retained in care after 12 months of enrollment. The findings from this retrospective study (RetroLink) are a call to action to assess and improve linkage services, and early enrollment and retention in HIV care in Swaziland.

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